Medication/Pharmacy errors...

[ObtundedRN, BSN, RN]

So working in the hospital, as a nurse, one of our responsibilities is to be the very last check that a medication is appropriate and safe for the patient. I catch pharmacy errors on a regular (and too frequent) basis. Usually it is simple mistakes, caused by any number of contributing factors. But sometimes I find big errors, such as pharmacy putting 3 runs of IV KCL on the wrong patient's eMAR, who happens to have a K of 5.1!

So if I find these errors in the hospital, it makes me question how often they happen outside of the hospital, where there is no nurse to help verify that the medication is correct.

Today, one of these errors happened to my newborn nephew. The retail pharmacy entered the wrong dosage on the label... 5 times the intended dose. This dose was fortunately still a safe dose, even for a newborn. So luckily the MD says there should be no cause for concern. But just the fact that this kind of error occured and for a newborn that isn't even a month old yet, is scary.

So please, everyone make sure you're verifing not only your patient's medications against the original MD order, but also make sure you and your family are getting the correct meds and doses from your own retail pharmacy.

[ZippyGBR, BSN, RN]

transcription errors is the principle reason the NHS retains a system where in -hospital drug charts are completed by a prescriber not by transcribing off 'orders' written elsewhere.

[Esme12, ASN, BSN, RN]

I also think the problem are the pharm techs with 6o hour online training and a GED filling these prescriptions. They lack the knowledge and insight training to be in such a critical position.

[merlee]

You are not kidding. Sometimes it can be a simple error - last week I picked up my refill of furosemide. I take 60 mg/day. It comes in 20 mg. They gave me a two month supply, but the bottle didn't seem very full. There were only 60 tabs in the bottle, not 180 as needed! And the techs acted annoyed as though it was MY fault!!!

Last year, my husband needed an antibiotic that he couldn't swallow, so the pharmacy had to call the doc to get approval for the liquid (pediatric) version. The equivalent dosage would equal 4 teaspoons, but the label read ONE teaspoon - a peds dosage - and they gave him ONE bottle! When I looked at it, I told him to call the pharmacy back to get the correct amt and a new label. It would have been a total waste otherwise. This pharmacy was very apologetic, but I still get the feeling it was only because they were caught!

If I wasn't a nurse AND I hadn't looked at it, he would have taken the peds dosage and may not have gotten better. Peds dose was 125mg, adult, 500mg.

Years ago, I had a patient over the course of a week who was on an 'LA' (long-acting) version of a med, and the capsule was 2 shades of green. I had a day off, and when I came back, the capsule was green and yellow. It was a different version of the med, not the LA. I checked to see if the order was changed, and it wasn't. I called the phamacy to report it and ask for the correct med. When I asked my supervisor about an incident report, I was told it was not necessary because the pt didn't get the wrong drug! But how to thwart this the next time???

We have to be ever-vigilent, at work and at home.

[Jackfackmasta, ASN, RN]

We just had an issue in my ER a week ago, the patient had the wrong blood band and wrong blood type on the band and luckily the ICU nurse caught it in time.

[NSGstudent12]

I am a pharmacy tech and have been one for almost 7 years. It is not our responsibility to check the medication before it leaves the pharmacy, thats why the pharmacist makes the big bucks! We fill what they verify, then they verify it again before it leaves. Anywhere you have people who have to make any decisions there are going to be errors. That's why we are human. Just like nurses, and doctors who make errors. I have found errors my pharmacist made before giving the med to the patient, but like I said they are human. It is best to check meds when you get them bc some are def gonna slip through now and then. I can honestly say that in the time I have worked in the pharmacy there were never any huge, harmful mistakes thank God. That doesn't mean they don't happen.

"People who make mistakes are people who do things." Author unknown.

[NSGstudent12]

And another thing, to say your med was intentionally filled wrong is just plain ignorant..(sigh)

[ckh23, BSN, RN]

And another thing, to say your med was intentionally filled wrong is just plain ignorant..(sigh)

I don't see where anyone said this.

[NSGstudent12]

"They only appologized because they got caught"

[kcksk]

When my son was an infant he needed neb treatments (prior to me being an RN). The dr said the amount of med I would be adding would be very small. Got the script filled and waited for a resp. tech to come teach us how to administer. Dose should've been 0.1ml of albuterol and the dose on the script was 1.0. Tech knew it was wrong right away. Called the pharmacy and they siad it was their error, MD had written it correctly. Hate to think what would've happened to my son, I think he was only a couple of months old at the time.

[SNIXRN]

Merlee,

It's odd that they said you didn't have to fill out an incident report - an error occured, not by you, but by another staff member, you were just smart enough to have noticed.

[nurseprnRN, BSN, RN]

for those who discover med errors in the hospital and get told to shrug it off "because nothing happened, you caught it," or some such, write it down and give them to your hospital risk managers. i promise you that they are interested, because some of these things stem from system errors, and it is their job to look at this sort of thing. they do want to hear from you.

if the error is from a commercial establishment, you can make a similar report to the corporate risk management department. in any case you ought to make it in writing to the pharmacist in charge, again, so system errors can be investigated.